By Arjun Sahgal and Mary Gospodarowicz
The following interview of Bernard Cummings, MB, ChB, FASTRO, was conducted on January 28, 2015, by Arjun Sahgal, MD and Mary Gospodarowicz, MD, FASTRO.
Arjun Sahgal: Great. Mary Gospodarowicz, and myself, would really like to thank Dr. Cummings for this interview here today for the ASTRO History Committee. We want to start off, Bernard, just a little bit about where you grew up and your evolution to ultimately where you became chair of the Department of Radiation Oncology at the Princess Margaret Hospital.
Bernard Cummings: I was born in New Zealand in 1942, and graduated from the University of Otago Medical School in 1967. The system in New Zealand at that time was that after completing your medical degree you did two years of what I suppose in North America would be called an internship. We called it a house surgeon position. During that time, I became interested in oncology. There was no specialty in medical oncology that time. There was a specialty loosely called either radiation oncology or clinical oncology and I eventually entered that program.
I was one of two trainees at that time. It was a very small department. The other trainee dropped out after six months. He went off and became a urologist. I really initially was primarily interested in the chemotherapy side of things, but after several months my preference switched to radiation. But I continued to keep chemotherapy of course because the New Zealand system at that stage and the Australian system were based on the United Kingdom model of clinical oncology where you train in both the use of chemotherapy, hormone therapy and radiation.
After I obtained my Australasian College certification, I, at the advice of my chief in New Zealand, decided to go overseas for some additional training at the fellowship level. One of my staff had previously undertaken a fellowship at the Royal Marsden Hospital in London, England and he arranged for me to go there for a year. But because of starting dates, there was a gap of about nine or ten months, and the staff said that I really should see some North American radiation therapy.
I was invited to go to Memorial in New York. But my wife and I were rather apprehensive about living in the United States, which to us was a very foreign country with a reputation for perhaps more violence than we were used to in New Zealand. My chief knew Dr. Bill Rider here at Princess Margaret Hospital, and after a couple of telephone calls I was invited to come here.
Mary Gospodarowicz: There was no Fellow Selection Committee that time.
Bernard Cummings: There was in fact another New Zealand fellow here at the time, a man called Alan Gray who later went on to be quite prominent as a radiation oncologist, particularly politically in New Zealand, for his involvement with the New Zealand Cancer Society.
In any event, I came here. I had been here about four weeks when I was with Dr. Ray Bush and he said to me one afternoon, I suppose you have to go back to New Zealand. Now, as it happened, I had planned to go back to New Zealand but had no contract commitment. And when I said, no, I didn’t have to go back to New Zealand, I found myself about half-an-hour later sitting with Dr Cliff Ash, who was the Director of the Ontario Cancer Institute/Princess Margaret Hospital, and being offered a job which I found very flattering. They did want me to go on to the fellowship at the Royal Marsden, which I did. While there, I became particularly interested in head and neck radiation treatment and had six wonderful months with Dr. Manuel Lederman who was one of the giants of head and neck radiation oncology at the time.
Mary Gospodarowicz: Did you work with Julian Bloom too?
Bernard Cummings: I worked with Dr. Julian Bloom for three months on CNS. Not on GU, on CNS. And I worked with Dr. Michael Peckham for three months on lymphoma. He was not really doing very much in the way of GU at that time. Here, at Princess Margaret, I had worked for about three months with Dr. Derek Jenkin in pediatric oncology; for three months with Dr Ray Bush in head and neck and gynecology cancers; three months with Dr Bill Rider in GI and GU cancers. That was about it because I was only here for nine months.
When I came back to Princess Margaret on the staff in 1974, we only had a very loose system of site groups. We tended to do everything. I have worked at one time or another for at least six months in everything except lymphoma. I had a very pleasant six months with Dr. Vera Peters working partly in her clinic and partly in my own clinic in breast cancer. I worked a lot with Bill Rider and became very interested in GI and head and neck cancers at that time.
I think that the three people that greatly influenced me, there’s no question that it was Ray Bush, Bill Rider, and to a lesser extent, Vera Peters - Vera Peters and her style with the patients. But I always felt when I finished working with Vera, that if I could second guess what she was going to do with the patient in 50 percent of the cases, that was a successful day. She was I think more intuitive in her assessment of patients than most other physicians that I’ve seen.
Mary Gospodarowicz: And maybe she just kept the evidence in her head.
Bernard Cummings: Well, she was rarely wrong. She would say this doesn’t look like a Stage 3; this looks like a Stage 4. Or it doesn’t look like a Stage 2. I don’t think that’s right. The only other person I’ve ever met who was like that was Manny Lederman. Manny Lederman could size up a head and neck patient extremely accurately and, again, with a certain degree of intuition.
Ray Bush was a model of a thinking radiation oncologist with a very wide background of knowledge in physics and in radiobiology. And Bill Rider was an iconoclast. Bill Rider, he really only had one word when you suggested how you were going to treat a patient. That word was “why”. You had to know the evidence for what you were doing. If the evidence was no good, he would ask how you would go about collecting evidence to make treatment more worthwhile. It was an interesting mix.
In the various wonderful philosophies that were followed in Princess Margaret, there was a very strong United Kingdom element, with two or three of the physicians who had trained in Edinburgh, and another subgroup of two or three who trained in London. Those philosophies were slightly at odds with each other, but that was interesting because by that stage I felt that it was possible to select out what was the best and to move on.
Ray Bush ran a very interesting clinic. It was called the Measurement Clinic. The Measurement Clinic was started by himself as the radiation oncologist and he was joined by Dick Hill who was here as a radiobiologist. There were two radiation oncologists who used to attend. I used to go and Andy Harwood used to go. Part of our job was to select patients with measurable lymph nodes, or measurable lung metastases, and then we would try different fractionations and see what sort of response we got by measuring growth in those various lesions.
It was a very interesting clinic. It did not persist for more than two or three years, particularly as Ray Bush became more involved in administration, but it was an interesting way of seeing that you could have a very useful contribution from having a radiobiologist actually present in the clinic. It’s something that I think is probably rare, if it happens at all, apart from those radiation oncologists who also have some training in radiation biology.
Now, here at the Princess Margaret, I continued to give chemotherapy as I had been trained to do both in New Zealand and in the UK. For several years, I was the only oncologist who was giving chemotherapy for GI cancer in this hospital. That was because the then head of medical oncology, Dr. Danny Bergsagel, believed that 5-FU was essentially an ineffective drug and that it was not worth the time of a medical oncologist to see patients with GI cancer.
So I was treating metastatic colorectal cancer and metastatic stomach cancer. The medical oncologists were quite happy to send those patients to me. That persisted for about four or five years, and then eventually I think Dr. Bergsagel’s colleagues persuaded him otherwise and medical oncologists started to get involved.
Mary Gospodarowicz: I remember that in the late ‘70s we had more radiation oncologists with American boards of medical oncology than we had medical oncologists with American boards of medical oncology.
Bernard Cummings: Well, that’s true. And because we had several young radiation oncologists here who had trained at least at their medical degree level in the United Kingdom, they were comfortable giving chemotherapy concurrently with radiation. The first combined radiation and chemotherapy given concurrently to a number of patients was 5-FU and mitomycin with radiation for anal cancer, which by sheer chance I heard about and introduced at Princess Margaret in 1978.
And because of the way site groups were then organized, new approaches could spread quickly. We worked on the principle that most people - in fact all people - were on at least two and usually three or four site groups, but they were not on identical site groups. So while I was in GI, other members of the GI group started using the drugs as well. But there were some of them who were working in gyne so that it was tested in cervix cancer. There were some who were working on head and neck cancers, including myself, so it was quite extensively used in head and neck and we were able to successfully mount a randomized trial with radiation, with and without 5-FU and mitomycin.
Mary Gospodarowicz: You did it on the bladder?
Bernard Cummings: It was done on bladder cancer. It was done on lung cancer. It was done on esophagus and rectal cancers. So of all of the drug combinations that have been tested with radiation, at Princess Margaret Hospital we probably had one of the largest experiences with 5-FU, mitomycin and radiation concurrently. But of course the only one which has persisted has been the anal canal treatments. And as I said, because so many of the radiation oncologists had some experience with chemotherapy, medical oncologists were largely uninvolved in the treatments with 5-FU, mitomycin and radiation early on.
One of the things that experience helped us with is that it established in Princess Margaret a pattern of concurrent radiation and chemotherapy which the current generation of medical oncologists has been much happier to collaborate in than perhaps some of the earlier ones in the early ‘80s.
Arjun Sahgal: How controversial was it at the meetings? Because you were presenting some of the early data for anal canal with spectacular results.
Bernard Cummings: It was not controversial in the sense of who gave the drugs or anything like that. People never really asked who gave the drugs; they asked what the results were. But I had the good fortune to be invited to present at a number of meetings particularly in the United States but also in Europe of colorectal surgeons. I don’t for a moment think that it was solely because of the results we got at PMH.
It was because Norman Nigro, whose name is attached to that combination, was a very well-known colorectal surgeon in the United States. He had given the program his blessing although in truth he was barely involved in the treatment being a surgeon, as surgery disappeared rapidly from the primary treatment of anal cancer. We always hear it called the Nigro protocol, as Dr Nigro was the first author on the first paper in 1974 describing the combination. But it was really the Vaitkevicius–Considine protocol because they were the oncologists who developed and delivered the treatment. Vaitkevicius was a medical oncologist. Considine was a radiation oncologist. They were all at Wayne State in Detroit.
Arjun Sahgal: Were the surgeons apprehensive then or did they still want to operate?
Bernard Cummings: Well, in Ontario, or at least I’ll narrow it down, in Toronto, it was not an issue. The reason it was not an issue is that there was a long tradition in many United Kingdom centers of treating anal canal cancer with radiation alone. Because there were several British trained radiation oncologists in Toronto and in Vancouver especially, those patients were already being referred for radiation treatment. So it was a very small step relatively to take the radiation that we were giving and add 5-FU and mitomycin.
What we did differently here from what was being done in the United States at that time, where it was a planned preoperative treatment with surgery at that stage being routine, was to make treatment definitive, and reserve surgery for residual cancer only It was unusual to take that approach and only if a patient insisted that, because they had had a complete response, they did not need an abdominoperineal resection. But that happened.
Here we had a tradition of treating the patients with radical radiation, and we simply took the 5-FU and mitomycin and gave them in very much the same doses that they had been given in the pre-op schedule. But the difference was that radiation in the Wayne State protocol was 30 Gy in three weeks, as a preoperative dose. We used a dose of 50 Gy in four weeks which was our standard radical dose. We simply grafted the chemotherapy onto that. It was extremely toxic in terms of acute side effects with proctitis and dermatitis. We did not see a lot of toxicity in terms of hematological toxicity, which was what has been a concern particularly with mitomycin. We did not encountered that. But the soft tissue toxicity was considerable.
As a result of the toxicity, we went through a series of evolving protocols initially using split-course radiation, then reducing dose per fraction to 2Gy and then 1.8Gy. We started off with what to our mind was a pretty radical dose, 50 Gy in four weeks. And then we moved with a lower dose per fraction to the order of 54 to 63 Gy range which is where we’re at. For larger tumors we are still using a somewhat higher dose of 63Gy at 9Gy/week. We appear to be getting better results with T3 and T4 tumors. But there is no question that there is late toxicity in terms of a disorder of anorectal function. That is something we are still wrestling with.
Even with IMRT, there’s no evidence at the moment to my mind that late morbidity will be less at the doses that we are using. Whether the late morbidity will be less at doses of 54 Gy or less typical in the United States, and the United Kingdom is using about 50 Gy, although planning for higher doses for larger cancers, I think is going to be something we need to watch.
One of the problems with recording morbidity particularly for anal canal cancer but also for rectal cancer is there is a tendency in the radiotherapy literature to report only Grade 3 or Grade 4 toxicity which is really quite severe. But you can have a level of incontinence or a certain amount of bleeding from the anal area which on the RTOG scale will be Level 1 or Level 2 and it’s simply not reported. Any degree of incontinence is a problem for patients. It inhibits them socially. And I think we need to still wrestle with this issue of how we report toxicity and of course how we manage it.
Arjun Sahgal: So that kind of brings us to an interesting point. Because we’ve seen really the evolution from delivering radiation based on clinical markup to 2D, the development of fluoroscopy, and then 3D and now 4D, and IMRT. I mean how did you handle that technical evolution, because it must have been really quite challenging during your training or during your professional life to manage that?
Bernard Cummings: Well, it’s not really challenging because it doesn’t happen overnight. It’s fascinating. I didn’t actually start in the 1D period but I can still remember learning how to treat cancer of the breast with 300 kV with extended SSD with the patient lying on a stretcher on the floor so that we could get the field sizes and the distance. I can still remember treating patients with bladder tumors and other deep-seated tumors radically with 300 kV. You have to remember that when I started in the early 1970s in New Zealand - and certainly in the United Kingdom when I was there - there were a number of cobalt-60 machines. There were very few linear accelerators or betatrons, but there was a great deal of orthovoltage equipment.
While most of the publications and the textbooks referred often to treatment with cobalt, that was often not practical. There simply wasn’t enough machinery available. People learned techniques to cope. We learned an enormous amount of surface anatomy because we would do setups clinically, before the evolution to fluoroscopic simulators. Now using the CT-simulator is something that you learn, but it doesn’t happen overnight. You’re using it every day. Some people become much more aware of what I’ll call the technical details and others tend to regard the machinery more as a black box but are aware of what it can do. If anything is challenging to me, it is finding that we are changing the planning system and I have to learn a whole new set of computer commands in order to plan a patient. But that’s not a reason for not evolving.
What have I seen as the biggest change? Probably the disappearance of cobalt and the widespread availability of the linear accelerator. I regard the changes with computing, engineering, MLCs, cone beam radiation, IGRT and all of that type of thing as really just subsets of change. But the key was the commercial availability of the linear accelerator as opposed to cobalt. There are still some things that I believe we could do better with cobalt than we can currently with the linear accelerator. I say that because sitting in the room with me is Dr. Gospodarowicz who got rid of the last surviving cobalt in this department.
Mary Gospodarowicz: Oh, yeah.
Arjun Sahgal: So what’s like an example of what we could do better with cobalt?
Bernard Cummings: You can treat anal canal cancer better with a direct perineal port with the cobalt unit. Particularly the one that we had which was a ceiling-mounted Philips, non-isocentric, which made it far easier to set up a direct perineal port than it is with electrons. Setting up electrons with patients in either the knee-chest position, which is not easy to achieve, or in lithotomy is technically difficult and difficult to reproduce accurately day after day. So that was one area that I would certainly regard that we --
Mary Gospedariwich: Probably protons now, right?
Bernard Cummings: Well, with protons, I have no personal experience. The general theory is the same, but it will all depend I think a lot on the applicators that have to go on the end of the machine for the setup.
Electrons of themselves are not limiting. What’s limiting are the attachments we have to put on the linear accelerator that make it awkward to verify that you’ve got your setup correct, because most of the verification of a direct port is done visually. It’s awkward to get in and look at the perineum when you’ve got an electron applicator, often with a cutout in place to shape the field. And it’s hard to actually be sure that you’ve got the same setup every day, not only on the skin surface but whether the angle is identical each day. So I still have a hankering for cobalt. On the other hand, I now am teaching residents who not only don’t know what a cobalt machine or a non-isocentric machine looks like, they barely know what orthovoltage is or let alone what an orthovoltage machine looks like. I think that while we can’t stop progress, there are times when I hanker for the old style.
Arjun Sahgal: Yeah. Well said. Along those themes, we’ve been dealing now with cone beam CT and image guidance. It’s all part of our routine basically in treatments. I mean if you’re looking at the upsurge of proton or particle-based therapy, there are those that think that this will become probably the linear accelerator of the future and this is what we will be treating with in 20 years’ time routinely. Do you believe that particle therapy has a potential for that impact?
Bernard Cummings: I believe it has potential for an impact. I think there are issues of cost not only of the equipment but whether one needs to rebuild a department in order to accommodate that sort of equipment. I think one of the areas where we are still very weak in radiation oncology, and where we don’t answer our colleagues who are in medical oncology well, is that we do not have good protocols for assessing or for developing the evidence that shows that a new technology is better than the old technology. I agree that it’s difficult to do, but it’s not impossible to do.
We have been very remiss, I think, in not mounting randomized trials to look at the different outcomes with protons versus photons, for example. It’s going to become even more problematic, I think, as we move on to introduce charged particles. Because, again, you’re going to be dependent on expert opinion and you’re going to be swayed by people who’ve got a lot of experience. They may be discounting some of their experience.
When I was a fellow in England, I was involved in selecting patients and sending them for neutron therapy for head and neck cancer. The group in London were strongly of the belief that neutrons were the way forward. At that site, the neutron was the particle of choice. However, Dr. Bill Duncan in Edinburgh mounted a randomized trial against a lot of opposition which showed that neutrons were not better. Everybody in London knew that neutrons had increased toxicity, but did not fully consider that. I had no doubt in my mind that neutrons were toxic.
I have never seen fibrosis such as I have seen in London at that time, but I was also aware of what was going on. I saw the patient population being picked over by the staff members who were selecting patients to go for treatment with neutrons. Some were tending to choose only the patients with very advanced tumors, and some made judgments and said let’s not give this person an experimental therapy, let’s do the traditional treatment.
You can’t do that in a randomized trial though. Either the patients meet the criteria and they are invited to go in or they don’t. And I think that we still are suffering very much from enthusiasm when it comes to considering protons. I am reasonably convinced that they’re an advantage for pediatric radiotherapy. I am not so sure that they’re necessarily an advantage for adult oncology. I think that there’s room to study them still. By no means have we exhausted the need for studies. And I would put protons with charged particles. They still need proper assessment.
Arjun Sahgal: So along those lines, I mean you’ve done so much scientifically. I guess, at what stage did you decide to change gear somewhat and go into administration and run the department?
Bernard Cummings: Well, it’s hard for me to look back and decide why I wanted to make that change.
Mary Gospodarowicz: There was nobody else.
Bernard Cummings: I’m sorry. I can’t hear you.
Mary Gospodarowicz: There was nobody else. Duty called. You cared about us.
Bernard Cummings: I would say the 1980s at the Princess Margaret Hospital was an interesting period. Bill Rider had retired. Ray Bush was the overall director and still a member of the radiation oncology department. Bill Duncan came as chief of radiation oncology and he invited me to be his deputy. And then I could see how decisions were being made. It’s always very revealing to attend meetings like MAC meetings and occasional board meetings to realize that what you as a clinical radiation oncologist might think is important may be of no interest to non-clinicians whatsoever. There are senior administrators who are primarily obsessed with dollars, with the budget.
Mary Gospodarowicz: Well, they must be.
Bernard Cummings: They must be, I accept that. I accepted that when I became chief. But what happened, there was a considerable of unrest in the hospital in the late 1980s. Ray Bush unfortunately passed away from lung cancer. His replacement as CEO was not an oncologist and was somewhat difficult to deal with. There were some new or enlarged program changes which were under-funded and affected existing programs. We ran into enormous problems with waiting lists for the first time and that was when I saw the value of having strong principles which are primarily patient-centered. In other words, could we provide appropriate treatment? I won’t say could we provide the best treatment, but could we provide appropriate and not inadequate treatment? And that was one of Bill Duncan’s great strengths. I won’t say that I learned it totally from him, but I did learn the importance of principles and being able to articulate them publicly.
We dealt with the waiting list at that time, but the price that was paid was that Bill Duncan and our chairman of the board and CEO did not see eye-to-eye on the way in which the problem was dealt with. Bill Duncan left and returned to Edinburgh. He’d had been chair of the Edinburgh University department and came to us as head of department. We did not have the university department at that time. And then he went back to Edinburgh, again as chair, and there was to be a search in Toronto.
There were two things happening at that time. One was that Princess Margaret Hospital needed a chief of radiation oncology, and the other was that the University of Toronto had finally agreed, after several overtures, that there should be an independent Department of Radiation Oncology separate from the Department of Radiology. They happened to coincide in terms of time, so they decided to do a joint search. I would describe myself, I suppose, as ambitious. I applied for this job and I had the good fortune to be accepted.
Mary Gospodarowicz: I thought we begged you to do it.
Bernard Cummings: Well, perhaps. Anyway, there were a lot of other things that were going on also. One of the decisions I made when I became chief was that if I was going to do administration, I would do a lot on it, and I would try to avoid having too many of the staff spending time in meetings which were not furthering the academic and clinical objectives of the department. So I took upon myself a lot of the committee meetings, very instructive, very interesting.
There are a number of other things that occurred during that period. We were relocating the hospital. Well, to put it in sequence - finishing the design of the new hospital, building an entire new hospital, commissioning 16 new linear accelerators (which cannot be done in a year). It took us two or three years to get that done. Our physics group was not only doing that, but were supporting the - I forgot the exact number - I think it was about eight to ten machines we had at the existing hospital on Sherbourne Street. We were running a satellite unit in the basement of another hospital on University Avenue which ultimately became part of the main Princess Margaret Hospital when we relocated to University Avenue. We were still running a clinic at Toronto General Hospital.
It was a very challenging and interesting period. We got our university department set up. Then late in the 1990s we ran into more waiting list problems. It fell to me to be the one to tell our CEO and the head of our cancer program that we could not continue to see patients at the rate we were seeing because we were simply falling behind and the waiting time between when we were seeing the patient and when the patient could start treatment was unacceptable. There is a principle in law, at least in Canada and I suspect it may be the same elsewhere, that once you have seen the patient, you are responsible for them. So your responsibility includes getting the patient referred appropriately to another center if necessary.
Now the difficulty in Ontario was that all of the centers were swamped. That meant confronting the government, who of course was not interested in bad publicity, and telling them that they had to look for facilities elsewhere. It wasn’t simply a question of putting up additional machines or further extending operating hours because we needed to have sufficient therapists particularly and physicists. Radiation oncologists I think could have managed with the numbers that we had although ideally we needed more, particularly if we were to maintain any academic programs, but we did not have sufficient therapists and we did not have sufficient physicists.
The Ministry Of Health, in its wisdom, then decided to do something that I agreed strongly with in principle; this was to move to a combined degree - diploma course, so a science degree and a diploma in radiation technology for the radiation therapists. The problem was that they did that without consultation with the radiation oncologists or as far as I could see with virtually anybody apart from the radiation therapists. The price of this arrangement was that for one year there was no intake into radiation therapy. That meant that we lost an entire year of graduates of radiation therapy from the province which just exacerbated the waiting list problem.
So my hair is now gray. My hair became very gray and very thin in the late 1990s because, again, I felt it was my job to review the request for treatment at Princess Margaret of every patient whom we might have to send away. We had made decisions as to which categories of patients would go. There were numerous phone calls of course from patients, from relatives, from those advocating on their part. Then of course we had to send many of these unfortunate patients elsewhere. A few were absorbed in Ontario. The majority ended up going to the United States, Buffalo and Cleveland in particular.
Arjun Sahgal: How did that situation then resolve itself? Because it was a difficult time, their morale was down. How did it all pick up both in terms of physicians and the department picking up and also then saw the solution to the wait list?
Bernard Cummings: Well, one of the solutions was the establishment of an evening clinic. We had tried to run extended hours at the hospital here. Our problem was that we could not get sufficient staff to run more than one or two linear accelerators for about three to four hours. That simply didn’t absorb the extra patients that we had. We were also very short of physicists at the time. There were issues of how we were going to make sure the machines could keep running and how the plans could be signed off and so on.
There was a clinic started in the evening which was run out of another hospital. It was run by staff who came from a variety of places and it was not a popular clinic with any of the radiation treatment-related professions. It was seen as not meeting the standards of care that most of the department would have wanted, particularly in terms of continuity of care. Because what you had was a different set of therapists every night on the machines. You had a situation where they were unable to recruit a physicist. Eventually a physicist was ordered by his hospital to sign off on all the plans at pain of being fired if he didn’t do that, and that certainly affected his health I know. And the radiation oncologists, by my recollection only one came from Toronto and I think two came from outside Toronto, travelling in for a couple of evenings each week.
It was a very difficult period politically. It was made more difficult by the rumors of the amounts of money that were being paid by the Ministry of Health to the physicians and staff who were providing that service, which was grossly above the amount that was being paid to staff who were treating the patients here during the day. The question that I think was asked quite rightly, why was a patient being treated at 8:00 at night worth more than a patient being treated at 9:00 in the morning.
It was a very difficult three years. I don’t pretend for a moment that we resolved it happily. What eventually happened was we were able to recruit additional therapists and physicists, and the numbers of patients fell to within the capacity of the organization in the province. o One thing that happened in Toronto is that some categories of patients, particularly patients who might have been treated palliatively, were not referred because of the delays. That has improved over the years only slowly.
I think one of the reasons for that is that palliative care was growing in the city and there were alternative methods to manage pain and so on other than radiation. So whereas radiation oncologists have been seen as often the physician of first resort for palliation of metastatic cancer, particularly that associated with pain, there were other physicians who became much more involved and were able to provide the support. But the proportion of patients receiving palliative radiation in Toronto is still less than it is in many centers. So, for example, in our own hospital the ratio is in the order of about 65 percent or 70 percent radical to 30 percent palliative courses. T That is not what you would see in a lot of other centers where it would be perhaps near 50:50.
Arjun Sahgal: As we draw to a close, in your experience scientifically and administrative-wise, I mean what we’ve been asking many of our interviewees for the History Committee is your advice for young academics who are entering into the profession because it is a different time than before. There are different pressures in terms of publications and grants that were very different from your time.
Bernard Cummings: Well, there’s no doubt about it. There’s more pressure on you as a young radiation oncologist now. I think there are several issues that one has to address. The first is does radiation oncology have a future. My answer is unequivocally yes for at least I would say another one to two generations. I am using that by analogy with how quickly effective drugs have been identified and introduced, how long it takes them to actually make a difference, and do they in fact replace radiation or surgery for that matter.
I believe, yes, that we will obviously go on developing new drugs. Maybe the pace will pick up. There’s no real sign that the pace of new drug development for managing established cancer as opposed to microscopic cancer is really picking up. But it may. So I don’t think there’s any need for the young trainee to worry that radiation oncology will disappear from under him. I think there is a major problem specific to Ontario, which is the issue of funding, but that’s a unique thing to how do you fund sufficient staff here. I suppose I could broaden that and say that’s a problem perhaps in Canada in general because of the way radiation oncologists are remunerated.
What would I advise them to do? I would advise them to get as broad a base as possible, a base of knowledge. I think we are hurting ourselves as a specialty at the moment by encouraging people to go very quickly into a fellowship where they choose often to concentrate on a technique. It may be stereotactic radiation. It may be brachytherapy. They don’t really develop a deep knowledge of the natural history of a cancer-type, and a good feel for how to apply the technique appropriately in other tumour sites.
It is all very well to say that what you learned to do in say CNS is equally applicable technically to cancer of the bladder. I simply don’t believe that’s true. You’ve got to also learn the disease and learn what the natural history is. So maybe you get that over two to three years. Maybe if the people who are doing the hiring want you to come and you say I’ve had a year’s experience doing this specialized tumor site knowledge or specialized technique knowledge, and that is applicable anywhere, then that is a weakness in staff selection, and unfortunately the way you have to go.
Personally I would rather see people doing what I call general radiation oncology for at least a couple of years and then being able to choose which sites they are really interested in. It may be if I was designing the perfect model, I’d say do a residency, go into a junior staff position on a rotating basis for two years, and then do a fellowship knowing or having some idea of where you want to go. That is not the model that I trained on, and I suppose it’s not strictly speaking the model that many people trained under.
The third, in my mind that you actually do manage patients better if you have a very deep knowledge of a particular tumor site or tumor type. And I do encourage people to be involved strongly in site groups. I think there are enormous advantages to being in two site groups although your academic productivity may be less than if you were in one. But the advantage of being in two site groups is that you meet a variety of colleagues in all specialties, and it’s that cross-fertilization that I find one of the great stimulants in radiation oncology. Should people try to be clinician scientists? Yes. But that’s a job for a few. And those people have to be identified by the department chief, encouraged and protected if need be, and they have to have a career path.
Arjun Sahgal: That’s wonderful. Mary, did you want to add anything?
Mary Gospodarowicz: I think you didn’t talk much about your role as a teacher. My area -- I remembered, Bernard, is because you have this broad experience, Bernard was the best person to go to when you were preparing for your exams because he could ask you the questions that nobody else would ever dream of.
Arjun Sahgal: He still does.
Mary Gospodarowicz: He’s like the holes in the knowledge. So I think there comes these generations of radiation oncologists that sort of owe you the fact that they’re better rounded individuals because of your deep probing questions but not enough to know where you have to understand. That’s what you said about Bill, right?
Bernard Cummings: Yes. That’s what I tried to learn from him.
Mary Gospodarowicz: When you had residents you worked with, it’s why you’re doing what you’re doing, what’s the evidence and constant questioning. You also were always very aware of the need to question what we do and questioning the evidence since it’s still relevant. I don’t know whether you want to talk about it for a few minutes.
Arjun Sahgal: We have a few minutes. So if you have some perspective on the education, we have two minutes.
Bernard Cummings: Well, I think education is enormously important. I very strongly believe in this. It used to be called the Socratic technique of question and answer, question and answer, and engaging the resident or trainee fellow on a one-on-one basis, particularly in the clinic. Lectures are okay. But the lectures are more, I think, for providing a little bit of perspective and a reference list. But you’ve got to know the literature and you’ve got to know, as Mary said, why are you doing this? Then you trace it back and you think, well, why on earth did they say that?
I think one of the most extraordinary things that we’ve done is translate what I’d call groupings of lymph nodes of anatomic convenience and saying that they have a biological significance. Do we have to treat the whole neck? Do we have to treat every lymph node on the pelvis? It’s interesting to look at the way that the management of some of the solid tumors and of lymphomas has diverged. I think the people who treat lymphomas are much better at looking at the biology of the lymph nodes than perhaps some of the rest of us are. But lymph node groupings do influence an enormous amount of what we do as radiation oncologists.
I think that one of the things in terms of education I’m particularly concerned about with the current trainees is what I’ll describe as their lack of knowledge of anatomy. They have some knowledge of axial anatomy from looking at lots of CT scans and MRIs, but they’re not really good at getting off the axial plane. I think that I also am very concerned with their lack of understanding of planning. Often the answer you’ll get when you talk about planning is, oh, I’d just ask the dosimetrist, I’d ask the physicist. That is not knowing how to be a radiation oncologist. If you’re going to say that, there’s only a very short step to saying, well, why doesn’t the medical oncologist send the patient down to the physicist and say I want the left leg treated. I think that radiation oncologists today are losing a lot of the skills that were required of us when we did not have the technical support that we have today.
For education, you’ve got to do a lot of reading. The trainees often say they’re too tired, they haven’t got time. Then I think that’s where we need to make sure they’ve got time.
Mary Gospodarowicz: It’s so much easier now. There’s Google.
Bernard Cummings: Yes, but there are problems. I think there are problems with electronic libraries, that the ability to browse is much more restricted than it used to be.
Arjun Sahgal: Okay. Well, with that, we’re going to conclude this interview. Both Mary and I thank you very kindly for making the time and allowing us to document your thoughts on radiation oncology. Thank you again.
Bernard Cummings: Thank you very much.